In this column, William F. Moroney reports on human factors/ergonomics issues that have appeared in the press. Your contributions are invited. Please send electronic copy with references to wmoroney1@udayton.edu.
Top 10 Patient Safety Concerns for 2022
, ECRI, https://bit.ly/3vkmIYa. ECRI criteria for selecting hazards include the following factors: severity, frequency, breadth (how many patients would it affect?), insidiousness, and profile (would the safety concern place a lot of pressure on the organization?). The top 10 patient safety concerns for 2022 include several with human factors/ergonomics implications. Specifically staffing shortages, COVID-19 effects on healthcare workers’ mental health, bias and racism in addressing patient safety, vaccine coverage gaps and errors, cognitive biases and diagnostic error, nonventilator healthcare-associated pneumonia, human factors in operationalizing telehealth, international supply chain disruptions, products subject to emergency use authorization, and telemetry monitoring. Human factor concerns can be found in most areas, but I will only address three. Staffing shortages increase the probability of errors. In 2020, there was an 18.7% turnover among registered nurses; shortages were also predicted among critical care doctors, hospitalists, respiratory therapists, and pharmacists. Cognitive biases (anchoring, confirmation, affect, and outcome) have led to erroneous diagnoses of COVID-19, which delayed appropriate patient care. Finally, human factors—specifically user-centered design—need to drive the operationalizing of telehealth, if we are to avoid the problems encountered when electronic healthcare records were initially adopted. In addition to identifying the hazards, the report includes recommendations to reduce the hazards, resources, and references. ECRI emphasizes the need for a total system approach, which is proactive rather than reactive and requires cross-stakeholder collaboration to solve safety problems.
Tesla Updates the “Yoke” Steering Wheel and Improves Its Ergonomics
. By Jorge Majdalani, March 24, 2022. https://bit.ly/3uDsfKo. In both the Tesla Model X and Model S, the steering wheel has been replaced by a rectangle-shaped yoke, like those used in commercial aircraft. “Among the features that the Tesla yoke included is the complete elimination of the typical levers that can be found behind the steering wheel and that are used for some basic actions such as turning on the turn signals, operating the windshield wipers or turning on the lights. In return, all these actions are available either on digital buttons on the steering wheel itself or directly on the central screen.” Consumer Reports evaluators (https://bit.ly/3JEVKQm) reported problems—specifically, in executing K turns and sharp turns, non-highway driving, and emergency handling, since the yoke shape precludes the use of the 10 and 2 o’clock hand positions. Additional concerns include the utilization of yoke-mounted touch buttons that replace the traditionally center-mounted horn button and the windshield wiper control, and up-down buttons have replaced the traditional turn signal stalk. The capacitive control buttons are susceptible to inadvertent activation. Finally, the gear shifter has been moved to the interactive screen located in the middle of the console. Preliminary findings suggest problems with transfer of training of overlearned driving skills can be expected.
Pedestrian Deaths Spike in U.S. as Reckless Driving Surges
. By Simon Romero, New York Times. Feb. 14, 2022. https://nyti.ms/3xgkc7Z. Despite fewer miles being driven in 2020, the pedestrian fatality rate increased 21%. Over the last decade, pedestrian deaths increased 46% compared with a 5% increase for all other crashes. Possible causes include the increase in the size of our slower moving aging population, streets designed for speed rather than safety, and increased size of SUVs and trucks (https://bit.ly/3jJYiSV). Additional pandemic-related factors include decreased traffic law, social disengagement (roles are suspended during pandemic), and angrier drivers. For additional details on the relationship between SUVs and pedestrian fatalities, see https://bit.ly/3LZdOpJ; https://bit.ly/3JBpQnL; https://bit.ly/36gEJOU; https://bit.ly/3vjjxQC. The situation is expected to get worse before it gets better https://bit.ly/3jxrLiK
Better Air in Classrooms Matters Beyond COVID. Here’s Why Schools Aren’t There Yet
. By Maria Godoy. NPR. March 14, 2022. https://n.pr/3Jzb01f. Improved indoor air quality in schools reduces infection rates and provides additional benefits. “When a room is better ventilated, influenza rates, asthma attacks and absenteeism go down, reading and math test scores go up. Less carbon dioxide builds up in a room, which helps students think more clearly.” See https://bit.ly/3jGo1eA. The average American school is over 45 years old and may lack mechanical ventilation systems or have inadequate ventilation systems (https://bit.ly/3jBIO39). Funding to improve ventilation systems is available through the American Rescue Plan Act (https://bit.ly/3uDnosE). Also see https://bit.ly/3rpCQ9H, https://bit.ly/3E9pyUd.
Former Nurse Found Guilty in Accidental Injection Death of 75-Year-Old Patient
. By Brett Kelman. NPR, March 25, 2022. https://n.pr/37P4MNe. A former nurse was convicted of gross neglect of an impaired adult and negligent homicide. She faces three to 6 years in prison for neglect and one to 2 years for negligent homicide and is scheduled to be sentenced May 13. She was acquitted of reckless homicide. She was accused of (https://cbsn.ws/3xspcGY) violating expected standard of care, selecting the wrong medication, and not reading the name of the drug or the red warning on top of the medication. However, a witness testified that it was common for nurses to override the drug distribution system to access drugs and the recently updated electronic record system led to delays in retrieving medications from the automatic drug dispensing cabinets. Additionally, there was no scanner in the imaging area for her to scan the drug against the patient’s ID bracelet. The American Nurses Association (https://bit.ly/3jzcCNV) decried the conviction as a dangerous precedent. “Vaught’s case is representative of a systemic problem, not a nursing problem.” “Rather than criminally prosecuting a nurse, we should be cross-examining the healthcare system that under-staffs its floors and overworks its nurses, making room for tragedies like this to happen. Healthcare needs an overhaul, for everyone’s safety and for the future of the nursing profession.” It is likely that this conviction will decrease the number of “close calls.”
Additional Links
2022 Medical Design Excellence Award Winners:
https://bit.ly/3O9eyum
Amazon Warehouse Injury Rates Twice That of Other Warehouses: https://bit.ly/3xspGNi and https://bit.ly/37P5qdC
When Motorists Look But Don’t See:
https://bit.ly/3KF2XB3
Razors Designed for Women
https://bit.ly/3xp9LiA
Making the Business Case for Safety Innovation:
https://bit.ly/3LZfdgc
As Weather Environment Changes, Better Flood Warnings Are Needed:
https://bit.ly/3xv6gHo
